Showing papers by "Michelle Shardell published in 2011"
TL;DR: The combination of behavioral mobile coaching with blood glucose data, lifestyle behaviors, and patient self-management data individually analyzed and presented with evidence-based guidelines to providers substantially reduced glycated hemoglobin levels over 1 year.
Abstract: OBJECTIVE To test whether adding mobile application coaching and patient/provider web portals to community primary care compared with standard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes.
RESEARCH DESIGN AND METHODS A cluster-randomized clinical trial, the Mobile Diabetes Intervention Study, randomly assigned 26 primary care practices to one of three stepped treatment groups or a control group (usual care). A total of 163 patients were enrolled and included in analysis. The primary outcome was change in glycated hemoglobin levels over a 1-year treatment period. Secondary outcomes were changes in patient-reported diabetes symptoms, diabetes distress, depression, and other clinical (blood pressure) and laboratory (lipid) values. Maximal treatment was a mobile- and web-based self-management patient coaching system and provider decision support. Patients received automated, real-time educational and behavioral messaging in response to individually analyzed blood glucose values, diabetes medications, and lifestyle behaviors communicated by mobile phone. Providers received quarterly reports summarizing patient’s glycemic control, diabetes medication management, lifestyle behaviors, and evidence-based treatment options.
RESULTS The mean declines in glycated hemoglobin were 1.9% in the maximal treatment group and 0.7% in the usual care group, a difference of 1.2% ( P = 0.001) over 12 months. Appreciable differences were not observed between groups for patient-reported diabetes distress, depression, diabetes symptoms, or blood pressure and lipid levels (all P > 0.05).
CONCLUSIONS The combination of behavioral mobile coaching with blood glucose data, lifestyle behaviors, and patient self-management data individually analyzed and presented with evidence-based guidelines to providers substantially reduced glycated hemoglobin levels over 1 year.
554 citations
TL;DR: Receipt of nafcillin or cefazolin was protective against mortality compared to vancomycin even when therapy was altered after culture results identified MSSA.
Abstract: The high prevalence of methicillin-resistant S. aureus (MRSA) has led clinicians to select antibiotics that have coverage against MRSA, usually vancomycin, for empiric therapy for suspected staphylococcal infections. Clinicians often continue vancomycin started empirically even when methicillin-susceptible S. aureus (MSSA) strains are identified by culture. However, vancomycin has been associated with poor outcomes such as nephrotoxicity, persistent bacteremia and treatment failure. The objective of this study was to compare the effectiveness of vancomycin versus the beta-lactam antibiotics nafcillin and cefazolin among patients with MSSA bacteremia. The outcome of interest for this study was 30-day in-hospital mortality. This retrospective cohort study included all adult in-patients admitted to a tertiary-care facility between January 1, 2003 and June 30, 2007 who had a positive blood culture for MSSA and received nafcillin, cefazolin or vancomycin. Cox proportional hazard models were used to assess independent mortality hazards comparing nafcillin or cefazolin versus vancomycin. Similar methods were used to estimate the survival benefits of switching from vancomycin to nafcillin or cefazolin versus leaving patients on vancomycin. Each model included statistical adjustment using propensity scores which contained variables associated with an increased propensity to receive vancomycin. 267 patients were included; 14% (38/267) received nafcillin or cefazolin, 51% (135/267) received both vancomycin and either nafcillin or cefazolin, and 35% (94/267) received vancomycin. Thirty (11%) died within 30 days. Those receiving nafcillin or cefazolin had 79% lower mortality hazards compared with those who received vancomycin alone (adjusted hazard ratio (HR): 0.21; 95% confidence interval (CI): 0.09, 0.47). Among the 122 patients who initially received vancomycin empirically, those who were switched to nafcillin or cefazolin (66/122) had 69% lower mortality hazards (adjusted HR: 0.31; 95% CI: 0.10, 0.95) compared to those who remained on vancomycin. Receipt of nafcillin or cefazolin was protective against mortality compared to vancomycin even when therapy was altered after culture results identified MSSA. Convenience of vancomycin dosing may not outweigh the potential benefits of nafcillin or cefazolin in the treatment of MSSA bacteremia.
214 citations
TL;DR: Chronic HCV all-cause mortality is more than twice that of HCV-negative individuals, which suggests that those with chronic HCV infection are at a higher risk of death even after accounting for liver-related morbidity and should be closely monitored.
Abstract: Background. Liver-related mortality among those infected with hepatitis C virus (HCV) has been described, but little is known about non–liver-related mortality. Our objective was to determine HCV-associated all-cause, liver–, and non–liver-related mortality in the general US population. Methods. A prospective cohort study of 9378 nationally representative adults aged 17–59 years was performed utilizing the Third National Health and Nutrition Examination Survey (NHANES III) Linked Mortality File that was made publicly available in 2010. HCV status was assessed from 1988 to 1994, with mortality follow-up of the same individuals through 2006. Results. There were 614 deaths over a median follow-up of 14.8 years. After adjusting for all covariate risk factors, HCV chronic infection had a 2.37 times higher all-cause mortality rate ratio [MRR] (95% CI: 1.28–4.38; P 5 .008), a 26.46 times higher liver-related MRR (95% CI: 8.00–87.48; P , .001), and 1.79 times higher non–liverrelated MRR (95% CI: .77–4.19; P 5 .18), compared with being HCV-negative. This represents an estimated 2.46 million US adults aged 17–59 years with chronic HCV infection who had an estimated 31,163 deaths from all causes per year, of which 57.8% (95% CI: 21.9%–77.2%) were attributable to HCV. Among those, there was an estimated 9569 liver-related deaths per year, of which 96.2% (95% CI: 87.5–98.9%) were attributable to HCV. Non– liver-related deaths were not significantly associated with HCV status. Conclusions. Chronic HCV all-cause mortality is more than twice that of HCV-negative individuals. This suggests that those with chronic HCV infection are at a higher risk of death even after accounting for liver-related morbidity and should be closely monitored.
142 citations
TL;DR: This is the first study to demonstrate an independent association between agr dysfunction and mortality among severely ill patients, and the δ-hemolysin assay examining agr function may be a simple and inexpensive approach to predicting patient outcomes and potentially optimizing antibiotic therapy.
Abstract: Accessory gene regulator (agr) dysfunction in Staphylococcus aureus has been associated with a longer duration of bacteremia. We aimed to assess the independent association between agr dysfunction in S. aureus bacteremia and 30-day in-hospital mortality. This retrospective cohort study included all adult inpatients with S. aureus bacteremia admitted between 1 January 2003 and 30 June 2007. Severity of illness prior to culture collection was measured using the modified acute physiology score (APS). agr dysfunction in S. aureus was identified semiquantitatively by using a δ-hemolysin production assay. Cox proportional hazard models were used to measure the association between agr dysfunction and 30-day in-hospital mortality, statistically adjusting for patient and pathogen characteristics. Among 814 patient admissions complicated by S. aureus bacteremia, 181 (22%) patients were infected with S. aureus isolates with agr dysfunction. Overall, 18% of patients with agr dysfunction in S. aureus died, compared to 12% of those with functional agr in S. aureus (P = 0.03). There was a trend toward higher mortality among patients with S. aureus with agr dysfunction (adjusted hazard ratio [HR], 1.34; 95% confidence interval [CI], 0.87 to 2.06). Among patients with the highest APS (scores of >28), agr dysfunction in S. aureus was significantly associated with mortality (adjusted HR, 1.82; 95% CI, 1.03 to 3.21). This is the first study to demonstrate an independent association between agr dysfunction and mortality among severely ill patients. The δ-hemolysin assay examining agr function may be a simple and inexpensive approach to predicting patient outcomes and potentially optimizing antibiotic therapy.
141 citations
TL;DR: Summer season and higher mean monthly outdoor temperature are associated with substantially increased frequency of BSIs, particularly among clinically important Gram-negative bacteria.
Abstract: Background
Knowledge of seasonal trends in hospital-associated infection incidence may improve surveillance and help guide the design and evaluation of infection prevention interventions. We estimated seasonal variation in the frequencies of inpatient bloodstream infections (BSIs) caused by common bacterial pathogens and examined associations of monthly BSI frequencies with ambient outdoor temperature, precipitation, and humidity levels.
131 citations
TL;DR: Mortgage delinquency was associated with significant elevations in the incidence of mental health impairments and health-relevant material disadvantage, and Widespread mortgage default may have important public health implications.
Abstract: Objectives. We evaluated associations between mortgage delinquency and changes in health and health-relevant resources over 2 years, with data from the Health and Retirement Study, a longitudinal survey representative of US adults older than 50 years.Methods. In 2008, participants reported whether they had fallen behind on mortgage payments since 2006 (n = 2474). We used logistic regression to compare changes in health (incidence of elevated depressive symptoms, major declines in self-rated health) and access to health-relevant resources (food, prescription medications) between participants who fell behind on their mortgage payments and those who did not.Results. Compared with nondelinquent participants, the mortgage-delinquent group had worse health status and less access to health-relevant resources at baseline. They were also significantly more likely to develop incident depressive symptoms (odds ratio [OR] = 8.60; 95% confidence interval [CI] = 3.38, 21.85), food insecurity (OR = 7.53; 95% CI = 3.01, ...
107 citations
TL;DR: Very low serum total carotenoid, α-carotene, and lycopene concentrations may be risk factors for mortality, but carotanoids show interaction effects on mortality.
97 citations
TL;DR: Patients with hip fracture who participate in a yearlong, in-home exercise program will increase activity level compared with those in UC; however, no significant changes in other targeted outcomes were detected.
Abstract: Hip fracture is a common problem with devastating consequences. At present, more Than 310 000 hip fractures occur annually in the United States,1 with an estimated cost of between $14 and $20 billion.2-7 By 2050, the number of hip fractures is expected to in crease to 700 000 in the United States and almost to 4 million worldwide.8 Between 16% and 32% of patients die with in a year.9-12 Among survivors, 50% need assistance to walk and 90% need assistance to climb stairs after 1 year.13 Furthermore, there are substantial changes in body composition;including loss of bone mineral density (BMD) of 4% to 7% per year, loss of lean body mass up to 6% within 2 months, and increase in fat mass of 3% to 4% in a year.13-16
On the basis of these findings under conditions of usual hip fracture care, it is important to identify novel interventions that older patients will comply with to ameliorate significant postfracture changes in order for gains to be realized beyond the 6-month recovery plateau observed for most functioning after hip fracture.17 Exercise is generally well tolerated by older adults after hip fracture with few serious adverse events18-20 and has the potential for increasing BMD and strength. Research has shown that weight-bearing, aerobic-type exercises alone or in combination with resistance exercises can slow or halt the rate of BMD loss in postmenopausal women.21-26 Unfortunately, the success of exercise in hip fracture rehabilitation, specifically, has varied. It is notable that few previous programs with this patient group lasted more than a few months,19,20,27 most began late in the recovery period,18,28 and with few exceptions19,27,29-31 most were gym or clinic based, rather than home based, which can limit access. Therefore, we designed a yearlong exercise program that could be delivered in patients’ homes in order to overcome the limitations of an extended center-based exercise program.
This study was designed to test the feasibility and identify preliminary indications of efficacy of the Exercise Plus Program, an aerobic and resistive exercise program administered after fracture by an exercise trainer in the home setting.32 We hypothesized that those randomized to the intervention, compared with those randomized to usual care (UC), would experience reduced losses in BMD, muscle mass, and strength; less increase in fat mass; greater increases in physical activity; improvements in ability to carry out physical and instrumental tasks of daily living; and increases in physical and psychosocial functioning.
87 citations
TL;DR: No association was found between frequent repositioning of bed‐bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioner, according to a 2004–2007 cohort study in nine Maryland and Pennsylvania hospitals.
Abstract: Frequent manual repositioning is an established part of pressure ulcer prevention, but there is little evidence for its effectiveness. This study examined the association between repositioning and pressure ulcer incidence among bed-bound elderly hip fracture patients, using data from a 2004-2007 cohort study in nine Maryland and Pennsylvania hospitals. Eligible patients (n=269) were age ≥ 65 years, underwent hip fracture surgery, and were bed-bound at index study visits (during the first 5 days of hospitalization). Information about repositioning on the days of index visits was collected from patient charts; study nurses assessed presence of stage 2+ pressure ulcers 2 days later. The association between frequent manual repositioning and pressure ulcer incidence was estimated, adjusting for pressure ulcer risk factors using generalized estimating equations and weighted estimating equations. Patients were frequently repositioned (at least every 2 hours) on only 53% (187/354) of index visit days. New pressure ulcers developed at 12% of visits following frequent repositioning vs. 10% following less frequent repositioning; the incidence rate of pressure ulcers per person-day did not differ between the two groups (incidence rate ratio 1.1, 95% confidence interval 0.5-2.4). No association was found between frequent repositioning of bed-bound patients and lower pressure ulcer incidence, calling into question the allocation of resources for repositioning.
57 citations
TL;DR: Patients with USA300 MRSA are more likely to develop severe sepsis in response to their infection, which could be due to host or bacterial differences.
52 citations
TL;DR: Findings indicate that at 2 mo post-hip fracture participants were engaged in very limited levels of PA, and age and comorbidities were the only variables to be significantly associated with PA outcomes.
Abstract: The purpose of this study was to characterize physical activity (PA) based on survey and ActiGraphy data from older adults at 2 mo post–hip fracture and consider the factors that influence PA among these individuals. The sample included participants from a current Baltimore hip study, the BHS-7. Measurement of PA was based on the Yale PA Survey (YPAS) and 48 hr of ActiGraphy. The sample included the first 200 individuals enrolled in the study, with analyses including 117 individuals (59%) who completed the YPAS and wore the ActiGraph for 48 hr. Half the participants were male, with an overall mean age of 81.3 yr (SD = 7.9). Findings indicate that at 2 mo post–hip fracture participants were engaged in very limited levels of PA. Age and comorbidities were the only variables to be significantly associated with PA outcomes.
TL;DR: To estimate meaningful improvements in gait speed observed during recovery from hip fracture and to evaluate the sensitivity and specificity of gaitspeed changes in detecting change in self‐reported mobility.
Abstract: OBJECTIVES: To estimate meaningful improvements in gait speed observed during recovery from hip fracture and to evaluate the sensitivity and specificity of gait speed changes in detecting change in self-reported mobility.
DESIGN: Secondary longitudinal data analysis from two randomized controlled trials
SETTING: Twelve hospitals in the Baltimore, Maryland, area.
PARTICIPANTS: Two hundred seventeen women admitted with hip fracture.
MEASUREMENTS: Usual gait speed and self-reported mobility (ability to walk 1 block and climb 1 flight of stairs) measured 2 and 12 months after fracture.
RESULTS: Effect size�based estimates of meaningful differences were 0.03 for small differences and 0.09 for substantial differences. Depending on the anchor (stairs vs walking) and method (mean difference vs regression), anchor-based estimates ranged from 0.10 to 0.17 m/s for small meaningful improvements and 0.17 to 0.26 m/s for substantial meaningful improvement. Optimal gait speed cutpoints yielded low sensitivity (0.39�0.62) and specificity (0.57�0.76) for improvements in self-reported mobility.
CONCLUSION: Results from this sample of women recovering from hip fracture provide only limited support for the 0.10-m/s cut point for substantial meaningful change previously identified in community-dwelling older adults experiencing declines in walking abilities. Anchor-based estimates and cut points derived from receiver operating characteristic curve analysis suggest that greater improvements in gait speed may be required for substantial perceived mobility improvement in female hip fracture patients. Furthermore, gait speed change performed poorly in discriminating change in self-reported mobility. Estimates of meaningful change in gait speed may differ based on the direction of change (improvement vs decline) or between patient populations.
TL;DR: To determine whether interleukin (IL)‐6 or soluble tumor necrosis factor alpha receptor 1 (sTNF‐αR1) is associated with depressive symptoms in the year after hip fracture, a large number of patients with a history of hip fracture are surveyed.
Abstract: Objectives: To determine whether interleukin (IL)-6 or soluble tumor necrosis factor alpha receptor 1 (sTNF-?R1) is associated with depressive symptoms in the year after hip fracture.
Design: Prospective cohort.
Setting: Three Baltimore-area hospitals.
Participants: Community-dwelling women aged 65 and older admitted with a new, nonpathological fracture of the proximal femur (N = 134).
Measurements: Two, 6, and 12 months after fracture, serum was analyzed for IL-6 and sTNF-?R1, and depressive symptoms were measured using the 15-item Geriatric Depression Scale (GDS). Generalized estimating equations were used to model the longitudinal relationship between IL-6, sTNF-?R1, and GDS score. Whether lower extremity function, as measured according to the Lower Extremity Gain Scale (LEGS), explained the relationship between IL-6, sTNF-?R1, and GDS score was also examined.
Results: Participants in the highest categories of IL-6 (?5.14 pg/mL) and sTNF-?R1 (?2,421 pg/mL) had the highest GDS scores in the year after fracture (P = .09 for both). Twelve months after fracture, those in the highest IL-6 and sTNF-?R1 categories had GDS scores that were on average 1.9 (95% confidence interval (CI) = 0.4�3.4, P = .01) and 1.4 (95% CI = -0.1�3.0, P = .07) points higher than those in the lowest category, respectively. Adjusting for LEGS score, the mean difference in GDS scores for highest versus lowest IL-6 categories was 1.6 (95% CI = 0.2�3.0, P = .02) points at 12 months.
Conclusion: Results from these exploratory analyses support a role for inflammation in the pathophysiology of depressive symptoms after hip fracture. Depressive symptoms in the context of high cytokine levels may represent a sickness syndrome that is chronic in some individuals. Further research should establish the cause and effect of this relationship, as well as long-term correlates.
TL;DR: A Web-based training course with embedded video clips for reducing central line-associated bloodstream infections (CLABSIs) was evaluated and shown to improve clinician knowledge and retention of knowledge over time.
Abstract: A Web-based training course with embedded video clips for reducing central line–associated bloodstream infections (CLABSIs) was evaluated and shown to improve clinician knowledge and retention of knowledge over time To our knowledge, this is the first study to evaluate Web-based CLABSI training as a stand-alone intervention
TL;DR: Evaluation of the association between pressure‐redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture finds no link between PRSS use and injury.
Abstract: OBJECTIVES: To evaluate the association between pressure-redistributing support surface (PRSS) use and incident pressure ulcers in older adults with hip fracture.
DESIGN: Secondary analysis of data from prospective cohort with assessments performed as soon as possible after hospital admission and on alternating days for 21 days.
SETTING: Nine hospitals in the Baltimore Hip Studies network and 105 postacute facilities to which participants were discharged.
PARTICIPANTS: Six hundred fifty-eight people aged 65 and older who underwent surgery for hip fracture.
MEASUREMENTS: Full-body examination for pressure ulcers; bedbound status; and PRSS use, recorded as none, powered (alternating pressure mattresses, low-air-loss mattresses, and alternating pressure overlays), or nonpowered (high-density foam, static air, or gel-filled mattresses or pressure-redistributing overlays except for alternating pressure overlays).
RESULTS: Incident pressure ulcers (IPUs), Stage 2 or higher, were observed at 4.2% (195/4,638) of visits after no PRSS use, 4.5% (28/623) of visits after powered PRSS use, and 3.6% (54/1,496) of visits after nonpowered PRSS use. The rate of IPU per person-day of follow-up did not differ significantly between participants using powered PRSSs and those not using PRSSs. The rate also did not differ significantly between participants using nonpowered PRSSs and those not using PRSSs, except in the subset of bedbound participants (incidence rate ratio=0.3, 95% confidence interval=0.1\u20130.7).
CONCLUSION: PRSS use was not associated with a lower IPU rate. Clinical guidelines may need revision for the limited effect of PRSS use, and it may be appropriate to target PRSS use to bedbound patients at risk of pressure ulcers.
TL;DR: Serum concentrations of both α- and γ-tocopherol were associated with better physical function after hip fracture, indicating that vitamin E may represent a potentially modifiable factor related to recovery of postfracture physical function.
Abstract: Background. Poor nutritional status after hip fracture is common and may contribute to physical function decline. Low serum concentrations of vitamin E have been associated with decline in physical function among older adults, but the role of vitamin E in physical recovery from hip fracture has never been explored. Methods. Serum concentrations of a- and g-tocopherol, the two major forms of vitamin E, were measured in female hip fracture patients from the Baltimore Hip Studies cohort 4 at baseline and at 2-, 6-, and 12-month postfracture followup visits. Four physical function measures—Six-Minute Walk Distance, Lower Extremity Gain Scale, Short Form-36 Physical Functioning Domain, and Yale Physical Activity Survey—were assessed at 2, 6, and 12 months postfracture. Generalized estimating equations modeled the relationship between baseline and time-varying serum tocopherol concentrations and physical function after hip fracture. Results. A total of 148 women aged 65 years and older were studied. After adjusting for covariates, baseline vitamin E concentrations were positively associated with Six-Minute Walk Distance, Lower Extremity Gain Scale, and Yale Physical Activity Survey scores (p < .1) and faster improvement in Lower Extremity Gain Scale and Yale Physical Activity Survey scores (p < .008). Time-varying vitamin E was also positively associated with Six-Minute Walk Distance, Lower Extremity Gain Scale, Yale Physical Activity Survey, and Short Form-36 Physical Functioning Domain (p < .03) and faster improvement in Six-Minute Walk Distance and Short Form-36 Physical Functioning Domain (p < .07). Conclusions. Serum concentrations of both a- and g-tocopherol were associated with better physical function after hip fracture. Vitamin E may represent a potentially modifiable factor related to recovery of postfracture physical function.
01 Jan 2011
TL;DR: Thecombination of behavioralmobile coaching with blood glucose values, lifestyle behaviors, and patient self-management data individually analyzed and presented to providers substantially reduced glycated hemoglobin levels over1year.
Abstract: OBJECTIVE—To test whether adding mobile application coaching and patient/provider webportalstocommunityprimarycarecomparedwithstandarddiabetesmanagementwouldreduceglycated hemoglobin levels in patients with type 2 diabetes.RESEARCHDESIGNANDMETHODS—Acluster-randomizedclinicaltrial,theMobileDiabetesInterventionStudy,randomlyassigned26primarycarepracticestooneofthreesteppedtreatment groups or a control group (usual care). A total of 163 patients were enrolled andincluded in analysis. The primary outcome was change in glycated hemoglobin levels over a1-year treatment period. Secondary outcomes were changes in patient-reported diabetes symp-toms, diabetes distress, depression, and other clinical (blood pressure) and laboratory (lipid)values. Maximal treatment was a mobile- and web-based self-management patient coachingsystem and provider decision support. Patients received automated, real-time educational andbehavioral messaging in response to individually analyzed blood glucose values, diabetes med-ications, and lifestyle behaviors communicated by mobile phone. Providers received quarterlyreports summarizing patient’s glycemic control, diabetes medication management, lifestylebehaviors, and evidence-based treatment options.RESULTS—The mean declines in glycated hemoglobin were 1.9% in the maximal treatmentgroup and 0.7% in the usual care group, a difference of 1.2% (P , 0.001) over 12 months.Appreciabledifferenceswerenotobservedbetweengroupsforpatient-reporteddiabetesdistress,depression, diabetes symptoms, or blood pressure and lipid levels (all P . 0.05).CONCLUSIONS—Thecombinationof behavioralmobile coachingwithbloodglucosedata,lifestyle behaviors, and patient self-management data individually analyzed and presented withevidence-based guidelines to providers substantially reduced glycated hemoglobin levels over1year.Diabetes Care 34:1934–1942, 2011
TL;DR: In general, highly cognitively and physically functioning hip fracture patients demonstrated higher vitamin E concentrations than expected, and the relatively high degree of function among this cohort of hip fractures may explain their higher-than-expected Vitamin E concentrations.